Provider Demographics
NPI:1962105601
Name:ORNELAS MARISCAL, FABIOLA STEPHANY (SUDCC)
Entity type:Individual
Prefix:
First Name:FABIOLA
Middle Name:STEPHANY
Last Name:ORNELAS MARISCAL
Suffix:
Gender:
Credentials:SUDCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 ARNOLD DR STE 225
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-4189
Mailing Address - Country:US
Mailing Address - Phone:925-655-2408
Mailing Address - Fax:
Practice Address - Street 1:1340 ARNOLD DR STE 225
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-4189
Practice Address - Country:US
Practice Address - Phone:925-655-2408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-22
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 172V00000X, 373H00000X
CA11405101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist